Virtual clinic in pregnancy and postpartum healthcare: A systematic review

Abstract Background and Aims To monitor the health status of pregnant women moment by moment, new technologies in the field of telemedicine can be used, such as virtual visits and virtual clinics. During the COVID‐19 pandemic, by using these technologies, useful and satisfactory services have been provided to pregnant mothers. The aim of this study is to specify the applications, features, and infrastructure of a comprehensive virtual clinic in the field of gynecological and pregnancy care. Methods A systematic review search was conducted through the scientific databases from February 2013 to February 2022 using Scopus, Web of Science, and PubMed. Furthermore, manual searches in Google Scholar and the reference lists of included studies were carried out. Results In this systematic review we included 16 articles that reported experiences in virtual clinics in pregnancy and postpartum healthcare. The involved studies were experimental, cohort, and cross‐sectional studies. The target group users were pregnant or women who gave birth and families of neonatal. The application of virtual clinics was for the visit, consultation, monitoring, follow‐up, and home care virtually. Highly satisfaction scores of caregivers after virtual visits and consultation were reported. There were some challenges during virtual visits and consultation; the most important challenge was a poor internet connection. Conclusion The reviewed studies show promising outcomes according to patient and provider satisfaction. We predict that telehealth will become a growingly significant part of gynecological care in the future.


| INTRODUCTION
Prenatal care and infant mortality rates have been identified as one of the quality indicators of care provision by the World Health Organization, while more than 44 million women in developing countries still do not have access to such cares. 1 Factors such as pregnancies in old ages (high-risk pregnancies) and unmanaged diet increase the risk of developing hypertension and diabetes during pregnancy. 2 On the other hand, due to the presence of chronic diseases in pregnant women, the need for continuous monitoring of the health status of them during pregnancy is inevitable. 3,4 To screen the health situation of pregnant women moment by moment, new technologies in the field of telemedicine can be used, such as virtual visits and virtual clinics. 5,6 Virtual clinics have benefits such as continuous monitoring of vital and clinical signs, saving time in providing care, reducing hospitalization and paraclinical costs, and increasing patient satisfaction. 7 Although telemedicine has grown in recent years, particularly to provide access to specialized care for patients living in rural or remote communities, telemedicine has rarely been utilized in prenatal care. 8 Also, before the COVID-19 pandemic, telemedicine was not routinely used in obstetrics.
However, after the declaration of a state of emergency due to COVID-19, the American College of Obstetricians and Gynecologists (ACOG) advised to arrange some appointments in the style of "telehealth" to decrease transmission of infection during clinic visits or due to having a meeting with healthcare staff. 9 During the COVID-19 pandemic, by using these technologies, useful and satisfactory services have been provided to pregnant mothers through virtual visits and health monitoring. 10,11 According to the searches conducted in the databases, scattered studies have been conducted on the use of virtual clinics for prenatal care focusing on the applications, capabilities, and infrastructure of virtual clinics for pregnant women. The purpose of this study is to specify the applications, features, and infrastructure of a comprehensive virtual clinic in the field of gynecological and pregnancy care.

| METHODS
This systematic review was carried out compliant with to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. 12 Systematic searches were done in the scientific online databases using selected keywords from February 2013 to 2022.

| Data sources
We performed a systematic search using three databases including Scopus, Web of Science, and PubMed. Also, we conducted manual searches in the reference lists and Google Scholar.

| Search strategy
Search strategies were written by the first and corresponding authors. Search terms are performed in a highly-delicate method via the Boolean operator OR. The search strategy is defined as follows: A. Pregnancy OR gestation OR prenatal OR perinatal OR neonatal OR antenatal OR childbirth OR "delivery care" OR postnatal OR postpartum OR "midwifery care" OR "maternal health" OR "postpartum program." B. Telemedicine OR telehealth OR telecare OR telemonitoring OR telehomecare OR teleconsultation OR tele-education OR "m-health" OR "e-health OR" "virtual visit" OR "virtual clinic" OR "virtual care" OR "virtual health."

| Eligibility criteria
The original and English studies that reported the design and implementation of the virtual clinic and virtual visit in maternal care were included. We considered the following exclusion criteria: (1) Non-original studies, including conference abstracts, review articles, protocols, and editorial.
(4) Original articles that don't report the design, implementation, and application of virtual clinic in maternal care.

| Selection study and data screening
We used the EndNote software version 9.0 to manage the retrieved studies. A single EndNote library was used to combine search results and duplicate studies were deleted. The articles were screened independently by two authors of the research team in different steps. First, the title and abstract of the studies were screened and the ineligible articles were deleted. Then, they investigated the full text of the remaining articles based on inclusion and exclusion criteria and the eligible articles were recognized.

| Data extraction
Required data were extracted by three authors of the research team as follow: first author, type of study, country target group users, applications, capabilities, infrastructures, benefits, challenges summary of findings. They managed the results of included articles in articles. The quality of the studies was surveyed by three independent and experienced authors. Any discrepancies in the quality of the selected studies between authors were judged by the first author and agreed with the majority. To assess the quality of the included studies the Newcastle−Ottawa scale was used ( Table 2). 27 According to three categories of selection, comparability, and outcome a maximum number of 9 was assigned to studies.

| RESULTS
We reviewed the available evidence on the virtual clinics in   9 thus the number of appointments has been reduced which on one hand, resulted in saving time, costs, and higher patients and providers satisfaction but on the other hand faced new challenges and required infrastructures. We will further discuss our findings in-depth.

| Appointments
Telemedicine interventions may reduce appointments for in-person prenatal care visits. The latest ACOG guidelines 9 suggested about 12−14 gynecological care visits, but several studies investigated a reduction from 14 patient visits according to 9 or even fewer visits because of the use of virtual nurse-midwife and physician visits, and remote monitoring for women with low-risk pregnancies. 14,17,22,[24][25][26] Different virtual visit schedules were developed by studies but the main frame was the same; after initial evaluation for enrollment by a physician, particular pregnancy milestones (i.e., the 8-and 20-week ultrasound, prenatal labs) were in-person visits and also the number of in-person visits increased with gestational age, due to the higher possibility of incidence of pregnancy complications. 17  to learn how to use these devices. 25 However, Doppler tones and also, non-stress tests for fetal monitoring couldn't be acquired for home use owing to the lack of reliable and commercially available remote monitoring equipment, but the qualitative assessment of fetal movement and the number of fetal kicks were possible to evaluate fetal well-being. 10 The data derived from these devices and a series of symptom-related questions were recorded on an electronic medical record platform or a cloud-based database by HCPs. 10 The costs of these equipment and funding resources haven't been mentioned in the studies; they may be purchased by patients, rented by hospitals, or provided by funding resources.

| Consultation
Besides reducing the number of in-person visits, assessment of fetal well-being, and monitoring and limiting weight gain, that is, consultation is one of the common benefits and usages of telemedicine which has been used for several years in

| High-risk
Expanding principles of telemedicine is not only used for routine prenatal care but also for management of high-risk pregnancies.
Hypertensive disorders of pregnancy are one of the leading factors of maternal mortality worldwide by affecting 2% to 8% of pregnancies in both developing and developed countries. 30,31 One of the main purposes and important aspects of virtual visits which most of the included studies in this paper performed was checking and monitoring blood pressure with a home cuff that is effortlessly available at local pharmacy stores or online. 10,14,[16][17][18]25,26,28 High-risk pregnancies with hypertension- The main reasons were as follow: the provider or patient technical problems, poor or lack of internet access, and lack of proper smart device. 10

| Virtual-versus in-person visits outcomes
There is an apparent concern that a decrease in traditional in-person

| Experience
The majority of the women who intended the virtual care were recommending it to others. However, Pflugeisen et al. 17 found that women who were in their first pregnancy may be significantly less likely to participate in virtual visits than women who are already mothers. Nelson et al. 25 showed that the virtual visit experience was comparable and admissible to the traditional in-person appointments for both patients and providers. Wichman et al. 19 reported 100% provider satisfaction with teleconsultation.

| Safety
Telehealth demonstrated to be an efficient option concerning patient safety. Several studies did not report significant differences in complications including, preterm delivery, cesarean deliveries, or birthweight among patients who received traditional prenatal care and those who received telehealth visits. 14 A major limitation of included studies was their lack of data on provider productivity and reduction of costs. None of the studies reported the cost effectiveness of virtual visits. There was no information about funding resources, or purchasing or renting equipment. As their first experience, the main goals of these studies were mainly to assess the safety, and satisfaction of the implementation of virtual visits for mothers and babies.

| LOOKING FORWARD
Results of the present study showed that virtual health is changing the healthcare landscape, and to stay competitive and on-use by patients, the traditional healthcare business models will need to be evolved. It is recommended to carry out further studies to investigate the impact of the virtual clinic on the total costs of treatment and the overall costs of establishing virtual clinics to show whether or not virtual clinics are economical in general.

| CONCLUSION
This review emphasizes the increasing use of telemedicine in obstetrics. It specifically evaluates telehealth infrastructures and types of interventions that improve existing prenatal care systems.
The reviewed studies show promising outcomes according to patient and provider satisfaction. We predict that telehealth will become a growingly important part of obstetric care in the future. However, barriers such as technology and maintaining quality will continue to require attention highlighting the importance of reliable support and infrastructure.